Principal Modality (1): CT Radiological Category: Gastrointestinal Principal

Principal Modality (1): CT Radiological Category: Gastrointestinal Principal

Principal Modality (1): CT Radiological Category: Gastrointestinal Principal Modality (2): General Radiography Case Report 696 Submitted by: Pooja Thakrar, M.D. Faculty reviewer:

Verghese George, M.D. The University of Texas Medical School at Houston Date accepted: 15 March 2010 Case History 28-year-old gentleman with abdominal pain status post crush injury. Radiological Presentations Radiological Presentations

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. Infectious colitis Physiologic free fluid Gastroenteritis Traumatic large bowel injury Ischemic colitis Inflammatory bowel disease Discussion

Physiologic Free Fluid A small amount of free fluid, particularly in the pouch of Douglas, can be physiologic in females and due to a ruptured ovarian follicle. Free fluid is never physiologic in males. Findings and Differentials Findings: Serial axial CT images demonstrate a small amount of free fluid adjacent to the descending colon. Additional images show fat stranding and soft tissue density in the left posterior abdominal wall and a transversely-oriented lucency through the base of the left transverse process of L3 with an associated mildly displaced bone fragment. No free intraperitoneal air is seen. Differentials:

Traumatic large bowel injury Infectious colitis Inflammatory bowel disease Ischemic colitis Discussion Traumatic Large Bowel Injury Generally, bowel injury will result in bowel wall enhancement and thickening as a result of increased vascularity and edema at the site of trauma. After all, injury begets inflammationnamely, cytokines released by damaged or dead cellsand inflammation is manifested as engorged blood vessels (hence the enhancement) and leaky capillaries (hence the edema). This is similar to the dolor, calor, rubor, and tumor seen clinically

with a superficial soft tissue injury. If bowel perforation has occurred, pneumoperitoneum can be seen as well. When enteric contrast is given, contrast extravasation into the peritoneal cavity may be present; however, in the acute trauma setting, given the need for rapid diagnosis, enteric contrast administration is often not feasible. In addition, an associated bowel wall or mesenteric hematoma, with or without active extravasation of intravenous contrast, may be observed and is in fact the most common manifestation of traumatic bowel injury. Bowel injury can result from any number of traumatic insults, ranging from the infamous bicycle handlebar in children to motor vehicle collisions or crush injuries. The mechanism can involve direct compression of the bowel against rigid structure, a sudden increase in intra-abdominal pressure, or an acceleration-deceleration phenomenon with a resultant mesenteric tear. Penetrating or

iatrogenic injuries are also potential culprits. Discussion Traumatic Large Bowel Injury The images provided demonstrate a small amount of free fluid along the distal descending colon (arrow) in the setting of an abdominal wall contusion and transverse process fracture (arrowheads). No free intra-abdominal air is seen, nor is any bowel wall thickening apparent. However, given the timing of the CT scan with respect to the

injury, it is likely that not enough time has elapsed for a sufficient inflammatory response to have developed. The key to making the diagnosis in this case is noting the bowel findings in the appropriate clinical settingthat is, knowing the patients history and identifying the concomitant injuries. Isolated free fluid as a marker of bowel injury is unusual. Discussion Infectious Colitis

Infectious colitis may occur as a result of overgrowth of a pathogenic microorganism within the colon. Etiologic agents include bacteria, fungi, viruses, and parasites. Clinically, patients may present with watery or bloody diarrhea, fever, abdominal pain or distention, and leukocytosis. Radiographic findings include thickened, edematous bowel (arrows), mesenteric fat stranding or reactive free fluid (arrowhead), and lymphadenopathy. While our patient had a small amount of pericolic fluid, no bowel wall thickening was noted to suggest inflammation. In addition, he lacked the clinical signs and symptoms of infection, making infectious colitis

an unlikely diagnosis. Images demonstrating infectious colitis in a different patient. Discussion Inflammatory Bowel Disease Inflammatory bowel disease (IBD) refers to ulcerative colitis (UC) and Crohns disease, both of which represent chronic illnesses of unclear etiology and which result in abdominal pain, diarrhea, and systemic symptoms. Crohns disease can involve any region of the gastrointestinal tract in a segmental fashion but tends to favor the terminal ileum. It causes transmural inflammation which can lead to strictures, abscesses, and fistula formation. UC begins in the rectum and spreads proximally but never extends

beyond the cecum (except for backwash ileitis); involvement in this disease is limited to the mucosa and submucosa. Patients with UC are at increased risk for developing colon cancer. In 10 20% of cases of IBD, extraintestinal manifestations such as arthritis, uveitis, or liver disease are present. Inflammatory bowel disease (Crohns disease) in a different patient. CT findings of IBD include bowel wall thickening (arrow) and mesenteric fat stranding. UC may demonstrate a shortened colon with loss of haustrations, and in Crohns disease, fistula formation, scarring with a resultant string sign, and abscesses may be seen. The isolated involvement of the descending colon

with only free fluid, especially in the absence of symptoms, makes IBD unlikely in our patient. Discussion Ischemic Colitis Bowel ischemia is usually a result of atherosclerotic disease of the mesenteric vessels but can occur for a variety of other reasons, including vasculitis, blunt abdominal trauma, fibromuscular dysplasia, cardiovascular collapse, or embolic disease. Venous infarction can occur in young patients, usually following abdominal surgery. Colonic ischemia tends to occur in watershed areas, those being at the splenic flexure and the distal sigmoid colon. Atherosclerosis and resultant ischemic colitis in a different patient.

Given our patients young age and lack of comorbid disease, recent surgical history, or evidence for hypovolemia, ischemic colitis is unlikely. CT findings include thickened, edematous bowel wall (arrows), mesenteric hyperemia, and, if perforation occurs, pneumoperitoneum or extravasation of intraluminal contents.

Atherosclerotic disease may be seen in mesenteric vessels (arrowheads). Discussion Traumatic Large Bowel Injury Subsequent plain radiographs diffusely dilated bowel representing ileus, likely as a result of peritonitis following perforation. The patient was taken to the operating room for bowel resection and creation of an ostomy. Diagnosis Traumatic large bowel injury.

References 1. Butela S et al. Performance of CT in detection of bowel injury. American Journal of Roentgenology 2001; 176, 129 135. 2. Kamm M. Inflammatory Bowel Disease. Martin Duitz Ltd. 1996; 14 31. 3. Nawaz Khan A. Colitis, ischemic. Emedicine 2009. 4. Peitzman A et al. The trauma manual: trauma and acute care surgery. LippincottWilliams & Wilkins 2007; 665 667.

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